A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole.
Which of the following statements by the client should indicate to the nurse that the medication is effective?

"My voice is no longer hoarse.”

"I am feeling more alert.”

"I don't have a headache anymore.”

"My appetite is increased.”

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Hoarseness of voice can be a symptom of an allergic reaction, indicating swelling and inflammation in the throat. If the client’s voice is no longer hoarse after taking diphenhydramine, it suggests that the medication has been effective in reducing this symptom.

Choice B rationale:

Diphenhydramine is an antihistamine and can often cause drowsiness as a side effect. Therefore, feeling more alert would not typically indicate that the medication has been effective.

Choice C rationale:

While headaches can sometimes be associated with allergic reactions, they are not a primary symptom that diphenhydramine targets. Therefore, absence of a headache does not necessarily indicate effectiveness of the medication.

Choice D rationale:

Increased appetite is not typically associated with the effectiveness of diphenhydramine in treating allergic reactions.

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Correct Answer is C

Explanation

Choice A rationale:

Hanging the antibiotic medication bag above the level of the primary infusion is an important step in administering an antibiotic via intermittent IV bolus. However, it is not the first step. The medication bag is usually hung higher to allow the antibiotic to infuse by gravity once it’s connected.

Choice B rationale:

Wiping the connection port of the primary IV tubing with an antiseptic swab is a crucial step in preventing infection. However, this is typically done just before connecting the secondary line, not as the first step.

Choice C rationale:

Checking the IV site for signs of infiltration is indeed the first step. It’s important to ensure that the IV catheter is still properly placed in the vein and that there are no signs of infection or infiltration, which could cause complications.

Choice D rationale:

Connecting the tubing of the medication bag to the primary tubing is done after cleaning the port and before hanging the bag. It’s not the first step.

A. "The first dose of this vaccine is given after the child is 3 years old.” B. "Give your child three doses of aspirin following administration of this vaccine.” C. "The vaccine should be avoided in children who have leukemia.” D. "This vaccine is contraindicated for children who are allergic to eggs.”

Correct Answer is C

Explanation

Choice A rationale:

The first dose of the varicella vaccine is usually given when the child is between 12 to 15 months old, not after 3 years.

Choice B rationale:

Aspirin should not be given to children due to the risk of Reye’s syndrome. This syndrome is a rare but serious condition that causes swelling in the liver and brain.

Choice C rationale:

The varicella vaccine should be avoided in children who have leukemia or any other condition that weakens the immune system.

Choice D rationale:

The varicella vaccine is not contraindicated for children who are allergic to eggs. It’s some other vaccines like influenza that have this restriction.

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A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole.Which of the following statements by the client should indicate to the nurse that the medication is effective?

Nursing Test Bank

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A nurse is collecting data from a client who received diphenhydramine 1 hr ago after developing an allergic reaction to trimethoprim-sulfamethoxazole.
Which of the following statements by the client should indicate to the nurse that the medication is effective?